Women and Mental Health Practice

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Women and Mental Health Practice

• Amy House, Ph.D.
• Medical College of Georgia
• March 2005

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OUTLINE

• What is gender?
• Gender differences in the prevalence and
  presentation of psychiatric disorders
• Factors that contribute to gender differences
• Attending to gender in clinical practice

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Case Example

• Michelle is a 35 year old, married, WF, mother of
  two children ages 11 and 7. She is presenting
  with symptoms of depressed mood, poor self-worth,
  worry, agitation, excessive sleeping, and
  overeating. She describes being depressed off
  and on since adolescence.
• She lives with her children, husband, and elderly
  father in a rural area of Georgia. She dropped
  out of school in the 9th grade, but later
  completed her GED. She is now self-employed
  part-time in a baking business out of her home.
  Her husband works full time as a truck driver.

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What is Gender?

• The meaning a culture gives to biological sex.
• Societal level Gender is a system of power
  relations
• Interpersonal level Gender is a cue.
• Individual level Gender is masculinity and
  femininity.
• It varies by culture, age, race, class, and
  sexual orientation.

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DSM-IV Diagnoses More Common in Women

• Schizoaffective d/o
• Shared psychotic d/o
• Major depressive d/o
• Dysthymic d/o
• Bipolar II d/o
• Panic d/o with and without agoraphobia
• Agoraphobia w/o panic
• Specific phobia
• Social phobia
• GAD

• PTSD
• Somatization d/o
• Conversion d/o
• Pain d/o
• Dissociative identity d/o
• All eating d/o
• Kleptomania
• Trichotillomania
• Borderline p.d.
• Histrionic p.d.
• Dependent p.d.

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DSM-IV Diagnoses More Common in Men

• Nearly all substance related disorders
• Factitious d/o
• All paraphilias
• Gender identity d/o
• Intermittent explosive d/o
• Pyromania
• Pathological gambling

• Paranoid p.d.
• Schizoid p.d
• Schizotypal p.d.
• Antisocial p.d.
• Narcissistic p.d.
• Obsessive-compulsive p.d.

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DSM-IV Diagnoses with Equal Prevalence

• Schizophrenia
• Delusional d/o
• Bipolar I d/o
• Cyclothymic d/o
• OCD

• Adjustment d/o
• Hypochondriasis
• Body dysmorphic d/o
• Avoidant p.d.

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Depression(Major Depression and Dysthymia)

• Twice as common in women than men
• National Comorbidity Survey
• WHO study of 14 countries
• Difference begins in early adolescence and lasts
  at least to midlife

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DepressionSymptom Presentation in Women

• More likely to present with
• reverse vegetative or atypical symptoms.
• expressed anger
• anxiety
• somatization
• Greater number of symptoms overall

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DepressionSeverity in Women

• Most studies find no gender differences in
  severity.
• Among chronically depressed
• Women have greater severity, younger age of
  onset, and greater family hx (Kornstein et al.,
  2000)
• Early onset adversely affects educational
  attainment and lifetime earnings of women, but
  not men (Berndt et al, 2000)

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Depression Precipitating Factors

• Women are more likely to become depressed
  following a stressful life event (Bebbington et
  al., 1988)
• Women are more sensitive to family events, men
  are more sensitive to financial difficulties
  (Kessler McLeod, 1984)
• Seasonal changes
• 80 of SAD sufferers are women (Leibenluft et
  al., 1995)
• Reproductive cycle events

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Course of Depression in Women

• No sex differences in age of onset of MDD
• Exception In chronically depressed, women had
  earlier age of onset (Kornstein, 2000)
• Longer episodes of depression
• More likely to develop a chronic or recurrent
  course

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Comorbidity

• Depressed women have higher rates of comorbid
  diagnoses than depressed men
• Phobias, generalized anxiety, panic, eating d/o
• Men are more likely to have comorbid substance
  use disorders
• No differences in overall rates of comorbid
  personality disorders
• More likely in men narcissitic, antisocial, OCPD
  (Kornstein et al., 1996)

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• Why are there gender differences
• the prevalence of psychiatric disorders?

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Biases in Diagnoses

• Clinical research samples are often skewed in
  gender representation
• Lack of continuity between childhood disorders
  most common among boys and adult disorders
• Bias within some diagnostic criteria creates
  lower threshold for female patients

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Bias in Clinical Judgment

• Clinicians make diagnoses on the basis of the
  representativeness heuristic
• Comparing person to typical case or stereotype
• Gender bias (and other kinds of bias) can occur
  because race and gender are features of
  stereotypes

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Biological factors in Women

• Estrogen and progesterone influence synthesis and
  release of both serotonin and norepinephrine
• Pubertal status is superior to chronological age
  at predicting risk for depression in adolescent
  girls
• Luteal phase of menstrual cycle and postpartum
  are frequently associated with dysphoric mood
  changes.

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Gender Role Socialization

• Differential emotional socialization of girls and
  boys
• The double binds of feminine gender role
• Emphasis on physical appearance
• Self-objectification associated with eating d/o
  behavior and depressive symptoms
• Coping styles
• Women more likely to use self-focused, ruminative
  style of coping in response to sadness.
• Men more likely to use distraction.

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Sexism

• Laboratory simulations of discrimination lead to
  increases in stress, aggression, sadness, and
  anxiety
• College women who experienced frequent sexism
  reported more depressive, anxious, and somatic
  symptoms than men.
• Those who experienced little sexism did not
  differ from men.

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Social status

• More women than men live in poverty many are
  single mothers.
• Poverty is one of the most consistent predictors
  of depression in women.
• Income inequality substantially increases risk
  for depression.
• Women achieve lower educational attainment
• Salary inequities in the workplace disadvantage
  women.
• Fewer gender differences in depression among
  college students.

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Social Status

• Gender differences in depression decreased by 50
  when men and women were matched for marital
  status, occupational status, and children (WHO
  study, Maier et al., 1999)
• Marriage less protective for women than men
  women in unhappy marriages more likely to become
  depressed.
• Women with less power in their marriages are more
  likely to be depressed.

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Violence Against Women Girls

• Women are much more likely than men to be victims
  of childhood sexual abuse, sexual assault, and
  intimate partner violence.
• 25 of women experience child sexual abuse 15
  experience rape
• Adverse childhood events are associated with
  depression, especially chronic forms of
  depression.

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Stress

• Across the life cycle, women report more
  stressful life events than men.
• Number of life stressors associated with
  depressive sx in adolescent girls.
• Women more likely than men to report a stressful
  life event in the 6 months preceding a major
  depressive episode.

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Stress

• Working women do a second shift of work at home
  (that men dont do).
• Women are primarily the caretakers of children
  and elderly in the family.

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• What are womens
• emotional strengths?

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Womens Emotional Strengths

• Emotional intelligence
• Women, on average, are better than men at
• Empathy
• Interpersonal relating
• Social responsibility (cooperation, contributing)

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Womens Emotional Strengths

• Better tolerance for others emotional distress
• Boys and men are more physiologically reactive to
  conflict and others distress, and are therefore
  more motivated to escape it.

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Womens Emotional Strengths

• Women tend to respond to stress by reaching out
  to others.
• UCLA research on stress and women
• Women have better social networks, and this may
  contribute to longevity.

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Gender Treatment Outcome

• Women respond better to SSRIs than TCAs.
• Effect is true for premenopausal but not
  postmenopausal women.
• The reverse is true for men. (Kornstein et al.,
  2000)
• NIMH Treatment of Depression Collaborative
  Research Program (Sotsky et al., 1991)
• No gender differences in response to CBT or IPT
• Among the severely depressed (Thase et al, 1994,
  1997))
• Women had poorer response to CBT than men
• IPT was comparable in men and women
• Among the chronically depressed (Keller at al,
  2000)
• Nefazadone and CBASP combined treatment equally
  beneficial for men and women

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Case Example

• Michelle is a 35 year old, married, WF, mother of
  two children ages 11 and 7. She is presenting
  with symptoms of depressed mood, poor self-worth,
  worry, agitation, excessive sleeping, and
  overeating. She describes being depressed off
  and on since adolescence.
• She lives with her children, husband, and elderly
  father in a rural area of Georgia. She dropped
  out of school in the 9th grade, but later
  completed her GED. She is now self-employed
  part-time in a baking business out of her home.
  Her husband works full time as a truck driver.

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Case of Michelle

• What other information do you want to know?
• What interventions should you consider?

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Attending to GenderReducing Bias in Clinical
Judgments

• Be aware of and sensitive to biases reported in
  the literature.
• Attend closely to diagnostic criteria
• Expose bias by asking What would I be thinking
  if this person were opposite gender?

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Attending to GenderAssessing Important Domains

• Quality and centrality of relationships with
  other women, men, and children
• Experience of limitations imposed by parents,
  peers, teachers, media
• Including experiences of discrimination/prejudice
  related to gender, race, age, class, sexual
  orientation
• Experience of violence/violations
• Self-evaluation of appearance and its centrality
• Eating/dieting strategy

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Attending to GenderClinical Practice

• Educate about gender inequalities in status and
  power
• Awareness of gender bias protects against
  depression (Major et al., 2003)
• Reframe clients definitions of problems to
  include impact of socialization
• Question and examine gender-role
  expectations/behaviors and their impact
• Help clients make gender-role changes and develop
  networks that will support changes
• Facilitate accessing community support
• Promote self-care

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References

• Garb, H. N. (1997). Race bias, social class bias,
  and gender bias in clinical judgment. Clinical
  Psychology Science Practice, 4(2), 99-120.
• Hartung, C. M., Widiger, T. A. (1998). Gender
  differences in the diagnosis of mental disorders
  Conclusions and controversies of the DSM-IV.
  Psychological Bulletin, 123(3), 260-278.
• Klonoff, E. A., Landrine, H., Campbell, R.
  (2000). Sexist discrimination may account for
  well-known gender differences in psychiatric
  symptoms. Psychology of Women Quarterly, 24(1),
  93-99.
• Kornstein Clayton (Eds 2002) Womens Mental
  Health A Comprehensive Textbook.
• Nolen-Hoeksema, S., Larson, J., Grayson, C.
  (1999). Explaining the Gender Difference in
  Depressive Symptoms. Journal of Personality
  Social Psychology November, 77(5), 1061-1072.